Ethical Question About Pacemaker
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Hi all! I have an ethical/end of life question for you. I had a patient who had a pacemaker placed in the 90s as well as an AVR a couple years previous to this visit. The patient was a young patient...
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I dealt with the same issue on a personal level. My grandmother had an AICD, and when we put her on hospice, the MD ordered the pacemaker rep out to "d/c" it. But he didn't write whether to d/c the pacer, the defibrilator, or both. The pacemaker rep disabled the defib but refused to stop the pacer itself, citing that a pacer will not keep a dying heart from dying. I argued that there was no need to have the pacer in a woman who was in MODS and expected to pass at any given moment, completely unresponsive (for days), DNR in place, literally with her family surrounding her, ready to go.

I should back up a bit and say that the pacemaker rep took forever to get there to turn the AICD off--12 hours in a patient who wasn't expected to even live another 12 hours. I had already had my brother go to the local Tractor Supply and buy me a big magnet. (I found it odd that the hospice nurse didn't have one? Is this not something they deal with on a fairly regular basis? Maybe not.) I refused to let my mom and her siblings see their mother being shocked just because the pacemaker chick couldn't find it in her busy schedule to get there and turn it off.

Anyway, to the OP, I think it was a huge oversight that the MD didn't write to have the pacer d/c'd in the patient. It was cruel and awful that the patient suffered and wasn't allowed to die as a result of this MD's negligence. You did the right thing. In my experience with dying patients, sometimes it takes a bit to begin to feel like you did the right thing.

Allowing someone to die is part of nursing (palliative care when ordered).

Making someone die is murder.

Sounds like the ethics committee needs to be involved

I do not think an ethics committee needs to be involved to remove a tube feeding, an IV, a vent, or to turn off a pace-maker, or any other similar mad made devices.
Removing heroic efforts, or man-made devices, does not equate to "murder", if if if if IF that is what you are suggesting.
(if i am misunderstanding your post, i apologize).

some of the cruelest of all deaths i've ever witnessed, were those when we kept some dying suffering human alive at all costs, oh my, those do break my heart, to see such suffering, and the extended suffering of the family nearby, as the person dies an inch at a time, thanks to all the technology.

Again, it is rare that a pacemaker will prevent a person from dying a "natural" death. Hospice rarely requests that pacers be DC'd.
Implanted defibrillators are an entirely different story and they should be DC'd as soon as the person elects a palliative rather than a curative approach to their terminal illness.

Hospices are charged with palliating symptoms to provide for a comfortable and dignified death. If discontinuing a pacemaker could be seen to hasten the death many hospices will defer that judgement to the family and will not participate in the process...to avoid any appearance of ethical conflict.

Just a little disclaimer, a person can still die while a pacemaker is active. I have looked up many a time and seen only pacer spikes only to be coding seconds later. Just for those who may not know.

I believe you did right as well. To me, it's about the patient. If he expressed his readiness to go and was in his right mind, let him go. Bravo to you! I know that had to be hard.

YES to this! My first code in my pedi cardiac ICU was a kiddo who was being internally paced, luckily (?) he was going down hill and I had the docs in my room already, one was already listening to him prior to his heart stopping and compressions were initiated as soon as the heart stopped. Meanwhile his moniter showed a beautiful 90bpm QRS

Think about it this way, the pacemaker is an artificial device. That device is prolonging their suffering, the patient was ready, by all means turn it off. It should have been addressed way earlier in this decision making progress.

Think about it this way, the pacemaker is an artificial device. That device is prolonging their suffering, the patient was ready, by all means turn it off. It should have been addressed way earlier in this decision making progress.

Welcome to the world of hospice where death, dying, and issues related to end of life are largely ignored by hcp's who are uncomfortable with the discussion. It is widespread and is in large part responsible for the vast amounts of money spent in the last 6 months of a persons life.

Allowing someone to die is part of nursing (palliative care when ordered).

Making someone die is murder.

Sounds like the ethics committee needs to be involved

I understand that way of thinking, but if it was the only thing keeping him alive when everything else had stopped working? I mean, his blood pressure was falling, he hadn't eaten in days, his kidneys had failed... I just felt like it was a way to let him go in peace in stead of forcing him to go through all of the pain and hurt of infection or some other problem.

They? There were more than one of these patients in your care? Please use singulars for one person; I thought "they" referred to his family or his caregivers and had to read this about three times to get it straight. Sorry to be so dense.

I did find this a little confusing to read, but once I figured it out, I was so glad that the patient was able to express his wishes and say he was ready to die. A pacemaker isn't any more magical than any other piece of medical equipment, as others have so ably described above. Anyone can refuse care of any kind at any time. It that patient had been me or a loved one, I'd have said, "20mg of MS push(4mg is almost homeopathic), count to ten, and turn it off."

I understand that way of thinking, but if it was the only thing keeping him alive when everything else had stopped working? I mean, his blood pressure was falling, he hadn't eaten in days, his kidneys had failed... I just felt like it was a way to let him go in peace in stead of forcing him to go through all of the pain and hurt of infection or some other problem.

We must not intend to cause death...
We must not intend to hasten death...
We palliate symptoms and allow them to die.

No offense but it seems some need to look into what pacers/ICDs are for eg what they do. What EP is, etc.

It's no biggy to turn off a pacer - it's done all the time. Hospice doesn't decide. You contact the EP and and get it done. They'll do it.

I'm tired of others deciding for patients what's gonna happen, even after I DON'T WANT THAT has been clearly stated.

When I want to leave this world, I'm thinking of hiring a true assassin to come get me. I want no meddling, and since it looks like I can't trust hospice to "get it" and let me make the decisions about my body (after all I'm paying them to do a job), I'd rather get the deed done quickly.